Daily Archives: May 7, 2007

Patient Presentation A 15-year-old female came to adolescent clinic with a lump in her left breast that she noticed 2-3 weeks previously.
It was painless and not changing in size. A soccer ball had hit her 1 week ago in that area and she said that she was bruised but the bruise had resolved.
She denies other trauma, skin changes, nipple discharge and had no fever or weight changes. She had normal menses and currently was having her period.
The family history was positive for diabetes but no cancer or breast disease.
The social history showed her to be good student who was not sexually active in the past or currently, and had no body piercings.
The review of systems was negative.
The pertinent physical exam showed a well-appearing female. She had a 1 x 2 cm ovoid, non-tender mass that was freely mobile, with regular margins that was located at ~11 o’clock next to the areola.
The rest of the breast tissue showed uniform, very finely thickened “cord-like” texture on palpation consistent with patient age and nulliparity. There were no other masses or axillary or other adenopathy.
The physicians felt that this was most likely due to a fibrocystic cyst, fibroadenoma, mammary ductal ectasia or trauma.
They considered abscess but the lack of historical or physical evidence made this less likely, and malignancy was also considered but because of her age and physical findings felt to be also less likely.
The physician instructed the girl return to clinic in two weeks for re-examination and to monitor and report any changes during the interval, especially if the skin was changing color, the mass increased in size or there was fever.
The patient’s clinical course continued as she returned to clinic two weeks later and reported that 10 days after the her previous visit she had some increase in mass size, and the skin broke down with discharge of yellowish fluid. She still had no fever. On examination she had a 4 x 3 cm mass with a punctum near the areola. The mass felt regular and no discharge could be obtained with palpation.
There was overlying skin redness, but no extension and some tenderness of the mass. The diagnosis of a breast abscess was made and she was placed on Cephalexin (Keflex®). She was to told to use warm packs. The radiologic evaluation of an ultrasound of the breast showed fluid and blood within the mass consistent with an abscess/hematoma.
She was also referred to a surgeon who saw her 7 days later. On examination at that time she had minimal discoloration of the area, a healed punctum and no definitive mass palpable.
The surgeon thought that maybe she had an initial fibrocystic cyst that because of trauma ruptured causing local irritation and hematoma. This later became infected producing the abscess.
This would be consistent because she had draining at the areolar margin which is classic for a subareolar process. She was to return to her primary care physician in another two weeks to confirm complete resolution.

Figure 49 – Sagittal ultrasound image of the upper outer quadrant of the left breast demonstrates skin thickening and a 4 cm mass-like area of disorganized breast tissue and edema with a small adjacent fluid collection. The constellation of findings was felt to represent an abscess.

Discussion

Thelarche is the onset of breast development and is usually the first sign of puberty in girls. It occurs at an average age of 11-11.5 years with a range of between 8 and 13 years.
The breasts grow over the next 2-4 years as classified by Tanner staging. If no breast development occurs by 13 years of age then this is delayed and an evaluation is warranted.

All adolescents should be examined and taught self-examination particularly adolescents with a family history of breast cancer or other malignancies. Risk factors for breast cancer include chest wall radiation and girls with a family history of breast cancer.

Most breast masses in children and adolescents thankfully are benign in nature.
Evaluation and management of breast masses depends on the history and examination. Ultrasonography is most helpful to characterize the lesion and can be performed serially. Mammography is not helpful because of the dense breast tissue of adolescents.
Aspiration and/or excision of the mass may be necessary.

Breast assymmetry – one side larger than the other, often because of initial thelarche

Mammary duct ectasia – benign dilatation of the subareolar duct resulting in inflammation and fibrosis, that usually has a bloody nipple discharge

Abscess

Mastitis

Hemangioma

Lymphangioma

Adolescent benign breast masses

Fibroadenomas – is the most common cause of adolescent breast pathology (67-94% of all causes). There is a localized exaggerated response to estrogen where the lesion increases in size usually over 6-12 months and then becomes stable. Most are 2-3 cm in size.

Fibrocystic breast disease – breast will have thickened, cord-like lesions that are diffuse and often because larger and tender with menses. Occurs in 50% of reproductive age women.

Questions for Further Discussion
1. What is the current age that most women should receive a screening mammogram?
2. What are the Tanner stages of breast development?
3. Describe the major pubertal changes in males and females in the proper order of appearance?

De Silva NK, Brandt ML.
Disorders of the breast in children and adolescents, Part 1: Disorders of growth and infections of the breast.
J Pediatr Adolesc Gynecol. 2006 Oct;19(5):345-9.

De Silva NK, Brandt ML.
Disorders of the breast in children and adolescents, Part 2: breast masses.
J Pediatr Adolesc Gynecol. 2006 Dec;19(6):415-8.

ACGME Competencies Highlighted by Case

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.

7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Practice Based Learning and Improvement
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
16. Learning of students and other health care professionals is facilitated.

Interpersonal and Communication Skills

19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

Systems Based Practice
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

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